Natural Therapies for Parkinson s Disease

Transcription

1 Natural Therapies for Parkinson s Disease Laurie K Mischley, ND PhD MPH Living Well with Parkinson s: Nutrition and Neuroplasticity 14 Apr 2018

2 Disclosures Advisory Boards: Brian Grant Foundation, Next Frontier Biosciences Consulting: Synapse Medical Intelligence Founder: NeurRx, Social Purpose Corporation Owner of PRO-PD scale (free scores available at Research funding: Michael J Fox Foundation, PD Families Institutional Affiliation: Bastyr University Clinical Practice: Seattle Integrative Medicine Apr Contact: info@educationismedicine.com

3 A Word about Natural Dopamine replacement as a therapeutic strategy. Both carbidopa & levodopa are naturally found in fava (broad beans) sprouts. Unnatural works very well sometimes- e.g. IM insulin/dm, MAO-B inhibitors, DBS Naturopathic Goals: Prevention; seek upstream influence. Alternatives to drugs & surgery: What else is there? Minimize unwanted side effects Optimize Quality of Life Use whatever works -

4 Lifestyle Modification is Hard Work People are resistant to change. This complacent approach to life is both cause/ consequent to disease: PD > apathy, depression, anxiety Socially withdrawing, not challenging self > PD We would all prefer easy, convenient disease-modifying strategies, unfortunately, they don t exist. Self-care requires investments in yourself. Popping a pill is easier than giving up your favorite food.

5 How Do We Know What We Know? Can we identify fast/ slow progressors? Can we identify modifiable behaviors associated with different rates of PD progression? NEXT STEP Pragmatic research If people who are doing poorly start doing the things that the non-progressors are doing, do disease outcomes improve?

6 Exercise Strategies for PD Increase heart rate Break a sweat Lymph drainage Requires intense focus Outside your comfort zone

7 The Constipated Brain Removal of debris Blood flow. (E.g. exercise) Enhanced autophagy. (E.g. lithium) Cellular detoxification. (E.g. glutathione) Brain lymphatic drainage requires sleep.

8 How Much Exercise is Enough? Rx: 30+ minutes of exercise daily. Minimum of 3 d/wk.

9 What Type of Exercise is Best? Cycling program Yoga Tai chi...boxing, dancing, slack-lining, etc. If you have a program you want us to collect data on, please send an to neuroresearch@bastyr.edu. Mischley LK MDS Poster: Diet, Exercise, & Supplements in PD

10 Exercise: Finding What Works for You Yoga is a great place to start. To pull it together Tai chi great for balance. Anything is better than nothing. Every day matters. Rock Steady Boxing, PD Cycling, Ballroom dance... Mischley LK CAMCarePD 2016, sample of raw data

11 Join a Group Exercise + Social

12 Social Health Touch: partners, pets Intellectual stimulation Challenging relationships are brain exercises Sense of belonging / community. Church Sports teams Family meals Helping others

13 The Value of Friendships A patient asked if he could make more friends and get away with less exercise. In preliminary data analysis, I am lonely has been the variable most correlated with progression. Mischley LK. Social Health in PD. WPC 2016

14 Diet in PD Food choices associated with fewest symptoms

15 Measuring Dietary Intake Food frequency questionnaires 24-hour recall Cameras, scales, apps

16 Diet: Encourage Fresh veggies Fresh fruit Nuts & seeds Non-fried fish Olive oil Coconut oil Wine Spices Fresh herbs

17 Plant-based Diets Reasonable Reservations More expensive [in the short term]. More trips to grocery store. More food prep required. Initially tastes bland. Family support sometimes lacking. Don t know what to eat. Weight loss concerns.

18 The Empowered Patient Patient-Centered Care Taking responsibility Lifestyle modification Make small, sustainable steps in healthier direction. Stress associated with rules & restrictions. Curve balls, discomfort, exploration > nurture neuroplasticity. Mischley LK 2017 MDS Poster

19 Top Natural Therapies for Parkinsonism Exercise Social health Nutrition: Diet, Sunlight Mindfulness Sleep Herbal Medicines Jury still out re: value of: TCM/ acupuncture Detoxification programs Chiropractic Ayurveda... hundreds of others.

20 Partners that Play for Points

21 Polyphenol Content of Food Cloves: 15,188 Dried peppermint: 7,929 Star anise: 5,460 Cocoa powder: 3,294 Dark chocolate: 1,664 Flaxseed: 1,528 (Perez Jimenez J. EJCN 2010)

22 Rx: Medi Diet How to prescribe? Who teaches? Financial support? CEO of Medi Diet? How to package & deliver?

23 Diet: Avoid Red meat, processed meat Dairy Cheese Yogurt Ice cream Fried foods Soda / Diet soda Canned Fruits Canned Vegetables Mischley LK, Diet & Supps in PD Progression.

24 The Quest for a Loophole What about soft cheeses? Goat cheese? Camel milk? What about grass-fed beef? But the milk I buy is organic. I only use a little bit of cream in my coffee.

25 Nutraceuticals Vitamin D Fish oil Glutathione Coenzyme Q10 CDP-choline Inosine Homocysteine-lowering vitamins Lithium

26 Nutraceuticals: Risks & Considerations Out of pocket costs, usually not covered by insurance. Questionable quality. Label claims don t necessarily match contents. Not regulated by FDA. Can t patent natural products, which deters investors/industry Commonly used in US, little guidance by conventional providers. Drug-Nutrient interactions Some make meds work better Some make meds work worse

27 Nutraceuticals Associated With: Improved Outcomes Coenzyme Q-10 Fish oil Worse Outcomes Iron supplements (Melatonin seemed to be due to poor sleep, not the melatonin.)

28 Inosine Gout seems to be protective. High uric acid seems to be protective. Risk: Inosine raises uric acid (which can cause kidney damage, gout) Can Rx: inosine slow PD progression? Study is underway:

29 Glutathione Reduced glutathione (GSH) is the primary antioxidant of the central nervous system (CNS). ~40% deficiency of brain GSH in early PD. Depletion comes before mitochondrial dysfunction, Protein aggregation, Lewy body formation, or Cell Death, loss of dopamine. Augmentation strategies have been explored since the 80 s.

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31 Phase I & II Studies (in)gsh in PD Safe & tolerable. Observed motor improvement in both; an appropriatelypowered Phase III study is required to determine whether (in)gsh is better than placebo. Mischley LK. Phase I Study of Intranasal glutathione for PD. 2015

32 Glutathione Augmentation Trials in PD Phase IIb- (in)gsh treatment arms & placebo has improvement in symptoms.

33 Vitamin D in PD Associated with: Slower bowel transit time Elevated hscrp Impaired balance, muscle weakness Depression Risk of dementia Required dose depends on: obesity, time outdoors, coverage of skin. Potentially toxic (Toxicity occurs ~ 300 ng/ml (Jones 2008).)

34 Fish Oil

35 Does fish oil reduce dyskinesia in humans?

36 Assessing Lithium Status

37 Lithium plays a role in: Regulation of autophagy Induced BDNF Enhanced neuro genesis Protects cells against glutamate-induced excitotoxicity Inhibits glutamate-induced Ca influx Magnesium homeostasis Mischley LK. Lithium Deficiency in PD, 2015 Haavaldsen R, Lancet 1973; Moore GJ, Lancet 2000; Bauer M Pharmacopsychiatry 2003; Fornai F, Autophage 2008; Sarkar S, J Cell Biol 2008; Su H, 2009)

38 CDP-choline in PD Over-the-counter supplement Precursor to neurotransmitter Ach Learning & memory Boosts effectiveness of levodopa ~ 30% enhancement Takes ~ 30 days to see effects

39 Coenzyme Q10 in PD QE3 study vs. Phase I, Phase II, & population studies

40 Homocysteine-Lowering Nutrients Levodopa use raises homocysteine levels. Due to interference with folic acid, B12, etc. Elevated homocysteine can be neurotoxic. Associated with: Dementia, l-dopa-related behavior abnormalities PD Progression (accelerates neurodegeneration)

41 Mindfulness Being present with self

42 Mindfulness Not the same as praying or spending time alone thinking. Meditation Yoga Mindful eating Fast walking MBSR course...

43 Rx: 8 week MBSR course Especially helpful for PwP that deal with anxiety, depression, stress, or difficulty coping with PD. Accessible. Standardized. Generalizable. Sometimes covered by insurance, offered at VA, etc.

44 Tai Chi & Qigong 21 published studies, 15 randomized controlled trials, 735 total PD patients Mind-body exercises like Tai Chi and Qigong... leads to clinically meaningful improvements in multiple domains of: Motor function Fall risk Mood Quality of Life

45 Yoga 3-month power yoga program in elderly PD patients Randomized controlled trial of 26 participants with PD Significantly reduced bradykinesia & rigidity Increased muscle strength and power

46 Herbal Medicines Cannabis, Mucuna, Tea

47 Access & Regulation of Cannabis Has been used medicinally for thousands of years. Federally regulation- Schedule 1 Schedule 1: No accepted medical use, high potential for abuse. State laws vary greatly, often in conflict with federal laws. Research plants come from University of Mississippi

48 Medical Use of Cannabis WHY DO PEOPLE USE IT? A survey of 1429 people who claimed to have used medical cannabis at least once in the previous 90 days. Non PD-specific study Top reasons for use: Pain Anxiety Depression

49 Cannabis for PD Social & political climate changing. Patients experimenting without physician guidance. Unique situation in medicine: Who is the expert? years of medical use; hardly any research. Value of anecdotal reports?

50 Cannabis in Parkinson s Mischley LK MDS poster. Manuscript under review. Quantitative data- motion sensor worn on wrist Decrease in tremor following Cannabis use. Qualitative interviews: 6/10 participants reported improved sleep.

51 Mucuna, Velvet Bean Ayurvedic medicine: Ancient tremor treatment. Naturally occurring source of levodopa. Does not contain carbidopa. Thus, higher doses of levodopa are required. Widely available in US as over-the-counter supplement.

52 Levodopa vs. Mucuna Research: In head-to-head trials, mucuna performs well. Hypothesis: Even though there is protein in plant and less levodopa, higher concentrations and smoother delivery may be due to presence of other molecules, eg. Q10. Over-the-Counter mucuna Concentrations don t match bottle label claim. Fear of contamination. Much higher doses of levodopa required (without carbidopa). Heart palpitations, sweating, nausea with high doses. In my clinical practice, I prescribe pharmaceutical carbidopa/levodopa, not mucuna.

53 CAM Training in Conventional Care Clinics Functional Integrative ND/MD/PhD collaborations Inter-office referrals, meeting at conferences, co-managing patients.. Systems need to be put in place.

54 Summary Treatment Plan Daily Exercise Intense, requires concentration Social Join groups, be needed Mindfulness Sleep Go to bed early Brisk walk outside each morning Plant-based (Medi) diet Encourage: Fresh vegetables/ fruits, nuts & seeds, fish, olive/coconut oil, wine, spices Avoid: Red meat, dairy, soda, fried foods, canned fruits/vegetables Individualized Plan for Supplements Keep all your providers informed. Fish oil, Q10, glutathione... Vit D, B-vitamins, melatonin...

55 Thank You! Living Well with Parkinson s: Nutrition and Neuroplasticity 14 Apr 2018